Nursing Elites

1. After a walk-in client enters the clinic with a chief complaint of abdominal pain and diarrhea, the nurse takes the client’s vital signs. What phase of the nursing process is being implemented by the nurse?

• A. Assessment
• B. Diagnosis
• C. Planning
• D. Implementation

Correct answer: A

Rationale: In this scenario, the nurse is performing the assessment phase of the nursing process. Assessment involves collecting data, which includes obtaining vital signs, to identify the client's health status and needs. This step is crucial for the nurse to gather information that will guide further decision-making in the nursing process. Choice B, 'Diagnosis,' would involve analyzing the collected data to identify the client's health problems. Choice C, 'Planning,' would be developing a plan of care based on the assessment findings. Choice D, 'Implementation,' is the phase where the nurse carries out the plan of care developed during the planning phase.

2. Which of the following is the correct abbreviation for drops?

• A. Gtt.
• B. Gtts.
• C. Dp.
• D. Dr.

Correct answer: A

Rationale: The correct abbreviation for drops in medical terminology is 'Gtt.' It is derived from the Latin word 'guttae,' meaning drops. The abbreviation 'Gtts.' (Choice B) is incorrect as it adds an unnecessary 's.' Choices C and D, 'Dp.' and 'Dr.,' are not standard abbreviations for drops in medical contexts, making them incorrect.

3. What is the initial technique used when examining a client's abdomen?

• A. Palpation
• B. Auscultation
• C. Percussion
• D. Inspection

Correct answer: D

Rationale: When examining a client's abdomen, the initial technique used is inspection. Inspection involves visually assessing the abdomen for any abnormalities, such as distention, scars, or rashes. This step allows the healthcare provider to gather valuable information before proceeding to other examination techniques like palpation, auscultation, and percussion. Palpation, auscultation, and percussion are secondary techniques used after visual inspection to further assess the abdomen for specific findings. Palpation involves feeling the abdomen for masses or tenderness, auscultation is listening for bowel sounds, and percussion is tapping the abdomen to assess for areas of dullness or resonance.

4. A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

• A. This medication is given to treat infection.
• B. This medication is given to facilitate ventilation.
• C. This medication is given to decrease inflammation.
• D. This medication is given to reduce anxiety.

Correct answer: B

Rationale: Vecuronium is a neuromuscular blocking agent that is used to facilitate ventilation by inducing muscle paralysis, which can help improve oxygenation in patients with ARDS. It does not treat infection, decrease inflammation, or reduce anxiety. Understanding the purpose of vecuronium administration is crucial for providing safe and effective care to patients with respiratory distress.

5. A client in labor is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

• A. Urine output of 20 ml/hr.
• B. Montevideo units constantly at 300 mm Hg.
• C. FHR pattern showing absent variability.
• D. Contractions occurring every 5 minutes and lasting 30 seconds.

Correct answer: B

Rationale: Montevideo units measure the strength and frequency of contractions during labor. A consistent Montevideo units reading of 300 mm Hg or higher is indicative of effective uterine contractions. In this scenario, an increase in the rate of oxytocin infusion may be warranted to further augment contractions and promote progress in labor. The other options, such as low urine output, absent variability in fetal heart rate, and short contractions, do not directly correlate with the need for an increase in oxytocin infusion rate.

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